In India, the healthcare delivery system starts up from the sub-center at the village level and reaches up to super specialty medical centers providing state of the art emergency medical services (EMS). These highest centers, located in big cities, are considered the last referral points for the patients from nearby cities and states. As the incidents of rail and road accidents have increased in recent years, the role of EMS becomes critical in saving precious lives. But when the facilities and management of these emergency centers succumbs before the patient, then the question arises regarding the adequate availability and quality of EMS. The death of an unknown common man, Rambhor, for want of EMS in three big hospitals in the national capital of India put a big question on the "health" of the emergency health services in India. The emergency services infrastructure seems inadequate and quality and timely provision of EMS to critical patients appears unsatisfactory. There is lack of emergency medicine (EM) specialists in India and also the postgraduation courses in EM have not gained foot in our medical education system. Creation of a Centralized Medical Emergency Body, implementation of management techniques, modification of medical curriculum, and fixing accountability are some of the few steps which are required to improve the EMS in India.

When Rambhor (50-year-old male), an unknown face in the crowd of millions of Indians, a vegetable vendor by profession, was hit by a speeding vehicle and thus died in the wee hours of November 30, 2010 in the national capital city of New Delhi for not getting emergency treatment for his injuries, he did not die alone. [1] Along with him died the healthcare delivery system of this country, unofficially. The death of Rambhor was not a routine death; his death symbolized the breakdown of the emergency medical services (EMS) in India.

Three big tertiary level hospitals in the national capital let Rambhor die for want of treatment. In the first hospital, he was refused treatment on the pretext of nonavailability of intensive care bed at that time. Second hospital (a trauma center) refused treatment as the Ultrasound machine was not in a working condition. The third hospital refused because the medicolegal papers were not complete. He was transferred from one hospital to another but denied treatment on one or another pretext. He died in an ambulance without getting any treatment.In this case, all the three hospitals flouted the orders of the Supreme Court of India. According to the apex court rulings, every state is bound to have a central bed bureau, under the health secretary, which maintains all records of bed availability in every specialty, such as the intensive care units across the state. [1]

Neither Indian law nor the orders of the Supreme Court and various High Courts of India have defined medical emergency. Therefore, the definition of medical emergency is still largely left to the discretion of medical professionals. [2] According to the American College of Emergency Physicians, an emergency is commonly defined as any condition perceived by the prudent layperson, or someone on his or her behalf, as requiring immediate medical or surgical evaluation and treatment. [3] Emergencies typically occur in cases like road accidents, cardiac problems, convulsions, and so on. Trained technicians or paramedics provide first aid to the patient, i.e., pre-hospital care, and then shift the patient to an appropriate facility. EMS is thus provided in two forms-pre-hospital services and treatment to inpatients. EMS is an essential part of the overall healthcare system as it saves lives by providing care immediately. [4]

Emergency Medical Services In India: Current Scenario

In India, a total 3.57 lakhs (0.35 million) accidental deaths were reported during the year 2009 with the Male-Female victim ratio of 77 : 23. The major unnatural causes of accidental deaths were road accidents (37.9%), railway accidents, and rail-road accidents (7.8%), poisoning (8.0%), drowning (7.7%), sudden deaths (7.4%), and fire accidents (7.0%). Deaths in "Road Accidents" in India have increased by 7.3% during 2009 compared with 2008. Most of the victims of accidents were aged between 15 to 44 years. This group of people has accounted for nearly two-third (60.7%) of all persons killed in accidents in the country during the year. [5] This is the economically productive age-group and major bread-earner of their respective families. Their untimely death due to accidents darkens the future of their families. Many of them die for want of timely EMS. Thousands of these accident victims could have been saved if timely medical intervention were available to them. [4] Thus, the need of quality EMS in India is an unmet need of the masses.

The healthcare delivery system in India starts from the sub-center level which caters to the need of approximately 5 000 population. At the peripheral level, there is a vast infrastructure of health services in India which comprises of 4 276 Community Health Centers (CHCs), 23 458 Primary Health Centers (PHCs), and 1 46 036 Sub-Centers (S/C) functioning in the country (as on March, 2008). [6] Irrespective of this, the country has not been able to provide the timely and quality EMS to masses, particularly in rural areas. As per a report of National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare (MOHFW), Government of India (GOI), a villager has to travel an average distance of 2.2 km (kilometers) to reach the first health post for getting a paracetamol tablet, over 6 km for a blood test, and nearly 20 km for hospital care. It is the private health sector to whom people look forward. The middle class and rich people prefer the medical services from the private sector. According to National Family Health Survey - III, in India, the private medical sector remains the primary source of healthcare for the majority of households in both urban areas (70%) and rural areas (63%). [7] Even the quality of private sector is also questionable.

Whenever there is medical and surgical emergency including the emergencies caused due to accidents, the patient is usually referred to the nearest city hospital after providing first-aid treatment. In very complicated and serious cases, the patient is further referred to big cities for treatment, irrespective of his/her family's financial condition. Sometimes, in these big cities too, the hospitals again refer these patients to specialty/super specialty hospitals for management. But the problem arises when these super specialty hospitals, which are the last hope for the poor and helpless families, are themselves ill and mismanaged. Most of the time, these big hospitals turned out to be of no use for the common man at the time of need. This happens because there is an unofficial dual system of healthcare delivery in India. The kind of services the people are entitled depends upon their economic status.

Emergency services are said to be the face of any hospital setup. The reputation of a hospital often depends upon the quality and promptness of its EMS. Most emergency departments in government hospitals and centrally run universities in India do not match up to the "Emergency Department Categorization Standards" proposed by the Society of Academic Emergency Medicine. [8] In India, the emergency care is offered in areas designated as "casualties" that are often manned by junior specialty residents with little overview and experience. Those who are most experienced in handling emergencies are usually not posted in causalities. Sometimes, doctors from the pre-and para-clinic subjects are posted to treat the emergency patients, particularly in cases of strikes of clinical doctors, and very rarely they are well equipped with the skills and experience to save a precious human life. By this kind of arrangement, the hospitals try to put every thing in place on the paper but compromise on the quality of EMS. So, the ultimate sufferers are the patients in distress.

The pre-hospital care is a neglected issue in India. No formal pre-hospital care was offered in 85% of the trauma patients as reported in a south Indian study. [9] Triage, something that is instrumental to good emergency care, is rarely practiced. There are no guidelines or regulations on the issue of pre-hospital care in most of the tertiary hospitals across the country. Most of the time, the emergency/casualty department, particularly of district-level hospitals, merely acts as "referral points" for specialized care in big cities. Problems are worse in rural areas where even the most basic emergency obstetric care has been found to be lacking. [8] The CHCs have not been developed enough to cater injuries occurring during small accidents. At most of the CHCs, the blood storage facilities are not available, thus rendering EMS ineffective in cases of emergency delivery cases. Along with it, there is no centralized emergency response body to coordinate the EMS in India.

Reluctance In Handling Medical Emergencies

It is an accepted norm across the world that in injured and critically ill patients, the priority of the doctor is to save life. However, often there is reluctance on the part of doctors to attend to the emergency needs of patients who, in medical jargon, are medicolegal cases. This unwillingness is largely due to medical professionals being unaware of their ethical and legal duties concerning the treatment of those brought to an emergency department. Also, there is an instinct among doctors to evade the inconvenience associated with subsequent lengthy and tiresome legal proceedings. [2] This is despite of the fact that the Supreme Court of India has clearly stated that the first obligation of a doctor is to save life and documentation and paper work could be performed later on. The court ruled that "zonal regulations and classifications regarding the jurisdictions of specialized police stations and government hospitals in a given area could not operate as fetters in the process of discharge of this obligation (to treat an emergency/injured victim)." In a concurring judgment, the court observed that "when a man in a miserable state, hanging between life and death reaches the medical practitioner (either in a hospital run or managed by the state, public authority, or a private person or a medical professional doing only private practice), he is always called upon to rush to help such an injured person and to do all that is within power to save life. It is a duty coupled with human instinct which needs neither decision nor any code of ethics nor any rule or law." [2]

Another factor for showing reluctance to serious emergency cases is to avoid the mortality in one's own hospital, particularly in case of private hospitals. More complicated cases are referred to higher center, particularly the government sector, because death of patient in their own hospital would bring bad name to the reputation of the hospital. Also, in case of death of their patient, the relatives often restores to manhandling of doctor/paramedical staff and damaging the hospital property. The action of police and local government administration like immediate arrest of doctor under mob/public pressure is another important issue. These kinds of incidences are increasing day by day and thus are responsible for doctors not handling the emergency cases (particularly medicolegal cases). This practice further leads to frequent referral of emergency patients to government hospitals, thus wasting the crucial time during which the serious patients could have been saved. Also, at government hospitals, there are no clear-cut demarcation of duties and responsibilities in emergency department. This leads to further delay in timely emergency services.

The Way Ahead

India is a country of paradoxes. On one hand, it has new corporate hospitals for attracting medical tourism and on the other hand, it has not been able to provide the basic primary health and necessary emergency services to the masses. There is a serious scarcity of working diagnostic machines, medicines, and infrastructure in its hospitals. Following are some issues related to emergency services which should be seriously discussed involving various stake holders without any further delay.

Creation of centralized medical emergency body

Trauma continues to be one of the major causes of death in India. To avoid preventable deaths and disabilities, India needs a common effective system that could provide quality emergency care with equity of access. As compared with developed countries with proper emergency systems in place, there was no single system which could play a major role in managing EMS in India. There was a fragmented system in place to attend the emergencies in the country. In a bid to address this problem, the Centralized Accidents and Trauma Services were set up by the Delhi Government in the early 1990s. This service was later expanded throughout the country. Unfortunately, it did not succeed despite having a toll free number -102 which is the emergency telephone number for ambulance in parts of India. [4] But, there are different emergency numbers in different states and Union Territories. So, there is an urgent need of a centralized Medical Emergency body which could provide guidelines for setting up emergency services with a single telephone number across the country. The centralized body should be involved in preparing protocols, imparting technical assistant, training, capacity building, and accreditation of emergency services. Procedures, protocols, and personal skills need to be standardized along with formation of legislation in parliament to provide legal protection for the providers of emergency services. [4] The initiative taken by the Gujarat state government in setting up the Gujarat Emergency Medical Services Authority is a welcome step in right direction. This was the first state to actually pass emergency services regulation in the country. By bringing together government, non-government organizations (NGOs), and other private agencies, a state-wide system of emergency care has been set up in Gujarat. [8] If India could have Securities and Exchange Board of India, Telecom Regulatory Authority of India, and Insurance Regulatory and Development Authority to regulate share market, telecom, and insurance services, respectively, then setting up a regulatory body for regulating the health services, particularly emergencies, could also be considered seriously.

Fixing responsibility and accountability

There should be clear-cut demarcation of duties and responsibilities in the emergency department. The duty roster including the contact number of concerned doctors should be assessable to public eyes. In case of grievances, there should be a responsible mechanism to address the complaint right there at emergency. Public relation officers should be posted at the emergency to handle the public grievances. The guidelines by the Supreme Court of India should be mandatory displayed publicly at emergency so that the doctors could be reminded of their duties and rights and the patients could claim treatment without failure. Most of time, the junior doctors have to face the ire of unsatisfied relatives of patients even when they are not responsible for procurement and maintenance of logistics. If the logistics are not in place or not working, this information should be brought to the notice of general public by publicly displaying the list of nonavailable services and logistics (which are supposed to be available in that hospital) and contact number of the senior officers/bureaucrats responsible for decision making. If the government is not providing the required fund and support, then it should come to the eyes of people through audit by authorized audit agencies.

Implementing hospital management techniques

The whole system of procurement of manpower and materials (including machinery and equipments/drugs), particularly in emergency department, should be managed with hospital management techniques. The time frame for every step of procurement and maintenance of emergency services should be clearly predefined. There should be introduction of compulsory "Annual Maintenance Contract" (AMC) clause for every purchase of medical equipment and its annual renewal. The companies not honoring the AMC should be black-listed. Strict action must be taken against those officials who sit on important files in greed of personal gains and are responsible for the delay in procurement and maintenance of life-saving drugs and equipments. If private/corporate health sector could practice good management techniques and succeed in their business ventures, why it cannot be replicated at government hospitals? To avoid mishandling with hospital staff, provision of adequate security at emergencies is required to protect the doctors from the wrath of patient's relatives and friends.

Implementation of the Indian public health standard guidelines

At present, the peripheral level health centers, i.e., S/C, PHC, and CHC, are nothing more than the referring centers. Even the basic life-saving services, manpower, and medicines are seldom available at these centers. As on March, 2008, as compared with requirement for existing infrastructure, there was a shortfall of 70.9% of Surgeons, 70.4% of Obstetricians and Gynecologists, 70.6% of Physicians, and 77.4% of Pediatricians at CHC level in India. Overall, there was a shortfall of 72.1% specialists at the CHCs as compared with the requirement for existing CHCs. [10] Thus, the patients who were referred to CHCs were just referred there for the sake of referral and to fulfill formalities. If these centers, particularly the CHCs, were equipped with basic life-saving facilities, then the patient could be stabilized there and then referred ahead. Thus, life of lot of emergency patients could be saved. Under the National Rural Health Mission, the Indian Public Health Standard (IPHS) guidelines have been framed which consists of the services, infrastructure, manpower, equipments, and drugs (to be provided at S/C, PHC, CHC, and District Hospitals). The IPHS guidelines considered these services in two categories of Essential (minimum assured services) and Desirable (the ideal level services which the states and union territories should try to achieve. [11] But still, these IPHS guidelines have not been made mandatory and not implemented fully across the country. The implementation of IPHS will certainly help in handling of emergency cases at CHC or at least ensure provision of life-saving procedures before referral to higher centers. In this way, the burden on higher health centers will also decrease in the long run.

Modification in medical education curriculum

The subject of EM has not been given the importance it deserves in Indian medical education system. The task force on "Medical Education for the National Rural Health Mission" constituted in 2005 under the aegis of MOHFW, GOI, has noted that within the time allotted to nonclinical subjects, a considerable portion is going into practicals. It observed that in some of the nonclinical disciplines-Pharmacology, Biochemistry-little purpose is served in allotting a significant portion of time. The task force suggested that the allocation of time to nonclinical subjects may be reviewed and should be made pertinent to applied aspect. Similarly, in case of internship, the common perception is that the students fritter away the period of internship. This is a year when the theoretical training is over, and the student is expected to learn hands-on knowledge during his/her attachment to various departments. [12] Most of the time during internship, the emergency duty is optional in many medical colleges across the country. The emergency duties should be made compulsory during internship and their tenure should be at least one month. After the completion of the internship, there should be a compulsory practical test to assess whether the interns have gained enough competency to provide certain basic emergency care independently or not.

Starting new postgraduate emergency medicine courses

There is a dearth of Postgraduate (PG) EM professionals in India. Very few institutes/medical colleges in India offer PG in EM. Thus, most of the emergencies are handled routinely by the concerned department after getting the call from junior resident/Emergency Medical officer. There is no separate department of emergency in many medical colleges in India. The emergencies are run by different units of all the clinical departments on rotation. In view of this, there is urgent need to create separate departments of EM. [13] The PG courses in EM should be commenced as soon as possible in the medical college hospitals. This will create a cadre of qualified doctors in EM in the long run and will change the face of emergency handling in India. Similarly, a cadre of Paramedical staff like nursing, technicians, and attendants should be trained specifically in EM.

Capacity building of pre- and para-clinical medical faculty

The doctors from pre- and para-clinical side are involved in teaching and research most of the time. Because of this, they remained cut off from the direct patient management. After few years of service, these doctors are short of knowledge regarding latest emergency management protocols and their clinical skills got blurred by passing time. So, in case of mass causalities and natural disasters, though these pre- and para-clinical doctors are counted as the available skilled medical work force, in actual only few are competent enough to handle emergency patients. This "pseudo-workforce" obliterates rather than facilitating the emergency relief work. So, there is an urgent need for capacity building of the pre- and para-clinical faculty. There should be an introduction of one-week "practical capsule course in emergency medicine" for every faculty member irrespective of his/her academic post. The faculty should be mandatorily made to attend this course every year and the curriculum of this course should be revised periodically.

Establishing emergency vehicle services network

The emergency vehicle services provided by some of the agencies in some states should be evaluated and implemented across the country. Principal among these are the National Network of Emergency Services at Ahmedabad, Delhi, Pune, Hyderabad, Chennai, Raipur, Ranchi, and Kolkata; Emergency Management and Research Institute (EMRI) at Haryana, Chandigarh, Uttarakhand, Rajasthan, Gujarat, Madhya Pradesh, Andhra Pradesh, Goa, Karnataka, Tamil Nadu, Meghalaya, and Assam. [8] The "108" telephone number for EMRI in Uttarakhand has been successful in providing EMS in hilly areas. There should be a common telephone number across the country for EMS. The staff on these EMS vehicles should be adequately trained and special attention is needed for their capacity building. The evaluation of their knowledge and practice should be done regularly to attain minimum standard of pre-hospital EMS care.

Increasing awareness among masses

People also need to take initiative in knowing about the services being provided under available EMS. Indeed, an EMS that people are not aware of is as good as nonexistent. One of the reasons for the success of EMRI is that 108 is widely recognized number and has a great recall among citizens. [4] The role of media could be instrumental in generating awareness regarding EMS by publishing success stories of EMS vehicles in saving precious human life. There should be a stepwise inclusion of "first aid Training Program" in the curriculum of school children. It should be made compulsory for teachers and students to attend these programs. The St. John Ambulance Association is a fine example of depicting that how imparting basic first aid training could save the lives of hundreds and thousands of people across the world. The school, colleges, universities, corporate houses, companies, organizations, and communities should come forward for getting training in first aid. More NGOs should be motivated to do work in this field.

Tax on hospitals promoting medical tourism

The medical tourism industry in India is provided with tax concessions; the government gives private hospitals (treating foreign patients) benefits such as lower import duties and an increased rate of depreciation (from 25 to 40%) for life-saving medical equipment. Prime land is provided at subsidized rates. The industry also gets a pool of medical professionals who got trained in public institutions for very less fees and then move to work in private hospitals-an internal brain drain, and an indirect subsidy for the private sector of an estimated Rs 500 crore per year. Thus, the price advantage of the medical tourism industry is paid for by Indian tax payers who receive nothing in return. [14] Thus, the imposition of some sort of "Public Health Tax" on these hospitals could be considered seriously. This extra revenue from medical tourism could be utilized to strengthen the healthcare services in India, particularly the EMS.

Conclusion

It has to be understood that routine doctors could not be relied upon providing emergency services in routine at emergency departments. Ideally, any medical graduate should be able to handle "emergencies" but it should be kept in mind that this is applicable in case of "real time" situations only (like out of the hospital scenario; for example, road accidents, emergencies in parties, etc., or in hospitals when emergency specialist are not present). In an organized sector like district/tertiary hospitals, the emergency should be handled by the experienced emergency specialists only as this is the question of life and death.

The importance of a reliable EMS cannot be over emphasized, especially in India where the government has the responsibility of caring for a majority of the population. The successful stories of some EMS in few states should be evaluated and replicated across the country. A public-private partnership framework could be the right way forward for policy-makers. At a time when the emphasis on preventing damage is greater than ever, the provision of pre-hospital care will be the key to ensure that lives are not lost due to avoidable circumstances. [4]

The EMS system has been ignored to a large extent in India. If the system is not being able to save the lives of its citizens, then it amounts to the collective failure of society and a system as a whole. It is nothing but criminal negligence from the part of government. The responsibility for this kind of criminal negligence should be accounted for.

What happened on November 30, 2010 is a matter of great concern to the society as a whole. It depicts the poor and worsening conditions of our system, particularly health. This incident should be utilized to start retrospection that how the deaths due to lack of emergency services could be minimized. One has to remember that a civilized country is not identified by its tall towers; rather, it is characterized by the way it behaves with and take care of its citizens. And at the end, our whole efforts to reconstruct and rejuvenate the EMS should be guided by the question raised right in the title of this article (and which still remains unanswered)-Who killed Rambhor?

National Crime Records Bureau. Accidental deaths and suicides in india-2009. Report. Ministry of Home Affairs, Government of India, New Delhi; 2010; 6-7. Available from: http://www.ncrb.nic.in/CD-ADSI2009/ADSI2009-full-report.pdf [Last assessed on 2011 Jan 28].

Rao KS. Delivery of health services in the public sector. Financing and Delivery of Health care Services in India. Background Papers of the National Commission on Macroeconomics and Health. Ministry of Health and Family Welfare, Government of India. New Delhi. 2005. p. 47.

Bulletin on Rural Health Statistics in India- 2008. Introduction- rural health care system in India. Infrastructure Unit, Ministry of Health and Family Welfare, Government of India, New Delhi. p. 1-13.

Ministry of Health and Family Welfare. Indian Public Health Standard (IPHS) for Primary Health Centres. Draft. Guidelines (Revised 2010). Directorate General of Health Services, Government of India, New Delhi, 2010. Available from: http://www.mohfw.nic.in/NRHM/IPHS_Revised_Draft_2010/PHC_Revised_Draft.pdf [Last assessed on 2011 Jan 25].

Report: Task Force on Medical Education for the National Rural Health Mission. Ministry of Health and Family Welfare, Government of India, New Delhi, 2005;32-40. Available from: http://www.mohfw.nic.in/NRHM/Documents/Task_Group_Medical_Education.pdf [Last assessed on 2011 Jan 25].